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How to deal with COVID-19 epidemic- related lockdown physical inactivity and sedentary increase in youth?
Adaptation of Anses’ benchmarks
Irène Margaritis, Sabine Houdart, Youssef Ouadrhiri, Xavier Bigard, Anne Vuillemin, Pascale Duché
To cite this version:
Irène Margaritis, Sabine Houdart, Youssef Ouadrhiri, Xavier Bigard, Anne Vuillemin, et al.. How to deal with COVID-19 epidemic- related lockdown physical inactivity and sedentary increase in youth? Adaptation of Anses’ benchmarks. Archives of Public Health, BioMed Central, 2020, pp.52.
�10.1186/s13690-020-00432-z�. �hal-02865819�
C O M M E N T A R Y Open Access
How to deal with COVID-19 epidemic- related lockdown physical inactivity and sedentary increase in youth? Adaptation of Anses ’ benchmarks
Irène Margaritis 1* , Sabine Houdart 1 , Youssef El Ouadrhiri 1 , Xavier Bigard 2 , Anne Vuillemin 3 and Pascale Duché 4
Abstract
Faced with the spread of the SARS-CoV-2 virus, regulatory measures aiming to prevent interpersonal contaminations have been undertaken and among these, lockdown. Due to strong restrictions out-of-home movements, we hypothesize that overall physical activity will decrease and sedentary behavior increase. This could result in highest exposure to the well-known risk related to insufficient physical activity. To mitigate physical inactivity and sedentary behaviors health-related risks related to children and adolescents lockdown and school closure, Anses (French Agency for Food, Environmental and Occupational Health & Safety) has adapted, within the first days of the public authorities ’ prescription, its former benchmarks. This paper supports and comments Anses ’ Opinion by raising the questions of whether, why, and how to deal with short- or medium-term lockdown-related physical inactivity and sedentary behavior increases. Short-term and unknown long term-impacts on mental health and well-being, physical fitness and eating behaviors clearly appearing for children and adolescents as being the main issues of concern are highlighted.
Targeting the compensations of the physical inactivity increase, the types, frequencies and durations of physical activity, are adapted to restricted environment. Sedentary behavior limitation and frequent interruptions becomes a priority. Overall, considering children and adolescents, the emerging risk justifies proposing specific adaptations and type of activities in order to ensure maintaining health underpinned, at least partly, by physiological equilibrium and physical fitness and avoid the installation of new unhealthy habits or routines that young people could keep after lockdown.
Keywords: COVID-19, Sedentary lifestyle, Behaviors, Screens, Children, Adolescents, Physical activity
Background
If children and adolescents seem relatively protected from COVID-19 infection, their health is affected by prolonged lockdown that may, in itself, trigger risks to the health and well-being of young people.
The major role of physical inactivity (PI) and sedentary behaviors (SB) in health-related risks and most chronic disease prevention has justified the publication of science-based benchmarks. These benchmarks for redu- cing the daily time spent in a seated position and for practicing regular physical activities (cardiorespiratory capacities, muscle building, balance and flexibility) have been updated by Anses (French Agency for Food, Envir- onmental and Occupational Health & Safety) in 2016 [1], considering usual social life and daily activities.
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* Correspondence: Irini.margaritis@anses.fr
1
French Agency for Food, Environmental and Occupational Health & Safety (Anses), Nutrition Risk Assessment Unit, 14 rue Pierre et Marie Curie, 94701 Maisons-Alfort, Cedex, France
Full list of author information is available at the end of the article
Since 17 March 2020, faced with the spread of the SARS-CoV-2 virus, responsible for the COVID-19 dis- ease, regulatory measures aiming to prevent interper- sonal contaminations, have been undertaken within the framework of the “state of health emergency”. France, like most countries, imposes strict lockdown measures for an announced period of several weeks that will prob- ably be followed by school closure and spontaneous self- restrictions until population feel new confidence for out- door activities. In this context, Anses has carried out the expert appraisal: “Assessment of the risks of reduced physical activity and increased sedentary levels in lock- down situations” linked to the COVID-19 epidemic [2].
This opinion relates to the healthy young population on lockdown in application of the French regulation – this issue is of international concern. Countermeasures are to date solely based on expert elicitation. Based on Anses’ opinion, updated by the most recent knowledge – especially on the current outbreak – this article raises the questions of whether, why, and how to deal with short- or medium-term lockdown-related PI and SB in- crease in young children and adolescents.
Main text Whether
Lockdown, as a maintenance of people in a space of re- stricted and closed volume, considerably limits move- ment, affects the spontaneous physical activity (PA) usually related to the necessities of daily life outside the home. The effect of these negative impacts associated with an insufficient level of PA of moderate to high in- tensity and a high level of PI or SB is widely recognized.
These effects have been identified and characterized for several populations, as a part of the report and opinion on the PA and SB benchmarks published in 2016 [1]. As an evidence, the strong restrictions out-of-home move- ments increase the exposure to these dangers, inducing an increase in associated health risks. The lockdown and the school closure prescribed by the public authorities during the current pandemic, and for several weeks, lead children and adolescents to restrict their movement.
To compensate for the decreased spontaneous PA re- lated to the necessities of daily out-of-home life and avoid or at least alleviate the effects of restricted daily movement, the types of PA, their frequencies and dura- tions have to be adapted.
Why?
Because physical health and fitness
Home care for children and adolescents is known to de- crease the level of PA and increase in sedentary time, in particular screen time [2].
In the context of the SARS-CoV-2 pandemic, lock- down is not total (certain outings remain authorized)
even if remaining associated with measures of “social distancing”. However, to characterize the dangers and hypothesize the risks, we have considered the worst-case scenario (this is to say that people do not exert outdoor activities) and postulate that the lockdown period will remain limited to a few weeks – despite the uncertain- ties as to the exact duration of this period and the condi- tions of the further social life recovery. To date, due to the lack of data, the so-called risk cannot be assessed, and the work has been realized based on strong hypoth- esis of modified exposures.
With the hypothesis that lockdown results in a de- crease in PA in young people, the situation can be simi- lar to a situation of detraining, even in young children (7 years old), strength and balance were assessed as weak after 8 weeks of detraining, i.e. stopping PA at school with or without strength training twice a week [3].
Because chronic disease risk
If PI and SB are associated with the risks of overweight, obesity and cardiometabolic complications, in return, regular PA reduces these risks and is associated with early mortality prevention helping preventing the onset of most chronic diseases [1]. Several experimental and observational studies emphasize that SB, and in particu- lar “TV time”, are associated with higher obesity and cardio-metabolic risks in children and adolescents [4]. In addition, other studies also highlight the associations be- tween the use of screens (especially television and smart- phones) and eating habits that can have a negative effect on health [5].
A sedentary lifestyle is a risk factor for chronic diseases and increased mortality. The context of lockdown promotes these SB and can lead to an increase in time spent sitting or lying down (apart from sleeping), the effects of which can be deleterious on health, including mental health.
It is known that the duration-factor of SB, the inter- mission plays a major preventing role. During a 3-h sit- ting position, regular break every 30-min (with 3 min of moderate intensity walking) in children of 7–11 years has been shown to lower insulin response and plasma free fatty acids to the consecutive meal [6] compared to uninterrupted SB. The very regular break in sedentary times by promoting PA, even if it involves low intensity and short-term PA is the first step in modifying SB pro- file [1] and is a point to emphasize. Overall, both consid- ering the daily time spent in a sitting position and respecting breaks for prolonged periods will potentially have effects on eating behaviors at risk of metabolic complications in children and adolescents.
Because diet
SB are associated with eating behavior leading to higher energy intake. To illustrate, a study [7] analyzed the level
Margaritis et al. Archives of Public Health (2020) 78:52 Page 2 of 6
of PA and the duration of SB on the specific effects of food intake. Energy intake is higher (+ 350 kcal) when SB times increase (corresponding to − 100 kcal of energy expenditure).
In addition, lockdown-related increases in SB can worsen food intake having potentially adverse health effects (e.g. increased frequency of snacking, consumption of energy-dense foods) [8] especially the consumption of sugar-sweetened beverages whose metabolic risks are proven [9, 10]. Moreover, an unbalanced diet could even worsen especially vitamin D status which is impacted by the lack of outdoor activities. In this re- gard, Anses points out the importance of ensuring sufficient intake by a balanced diet including vitamin D-rich foods.
1Overall, to reduce both nutritional and metabolic risks, the interruption of SB is of prime importance.
Having healthy nutritional habits is essential in this context, necessarily associated with measures to re- duce PI [9–11].
Because mental heath
The recent lockdown in China during the current COVID-19 epidemic showed high levels of anxiety and stress. Anxiety is associated with an increase in cortisol se- cretion whom rhythm of secretion is disturbed, and the quality of sleep is affected. The recent experience in China shows that children in the younger age group (3 – 6 years) were likely to manifest symptoms, such as clinginess and fear that family members could contract the infection.
Children aged 6 to 18 years were more likely to show in- attention [12] or have affected mental health as by other traumatic experiences [13]. Another study in young people aged 14 – 35 years reported 40.4% of psychological problems and 14.4% of Post-Traumatic Stress Disorder symptoms [14]. Expecting upcoming data, these emerging signals encourage considering the role of lifestyle includ- ing getting enough PA – to limit PI – and SB limitation which can both contribute to mental health protection [1], especially in children and adolescents in the context of school closure and lockdown.
How?
To move toward new benchmark proposals, the bench- marks developed in 2016 for children and adolescents [1] – as they are underpinned by the assessment of health risks related to PA and SB – have been adjusted to benchmarks suitable for lockdown (as summarized in Table 1). To reach this goal, the adjustments have taken into account the reduction of daily activities imposed by high restriction for people to leave home and engage in
regular activities (e.g., school, work) or access to places of PA practice (e.g. parks, walking trails, etc.), even near the home.
Anses considers here the relevant handles from it opinion [1] to put them into perspective of lockdown and proposes the appropriate benchmark statements.
The adaptation of PA practice rules is imperative for physiological (maintenance of muscular functions, bone health, body composition, etc.) and psychological health (recreational activities allowing tightening the family ties in a general context of anxiety).
From former to adapted benchmarks: physical activity The PA benchmarks for children under 6 years are at least 3 h per day of PA, i.e. 15 min/h for 12 h of wakeful- ness remain applicable during lockdown. However, the PA benchmarks for children aged 6 to 17 are at least 60 min/d of moderate to high intensity PA need to be adjusted.
In children aged 6 to 17 years, the PA benchmarks should maintain a total duration of 60 min accumulated per day (PA duration has to be measured). This duration can be split into a period of 10 to 20 min several times a day (to be distributed). A moderate intensity has to be maintained at least over two 10-min periods and muscle reinforcement has to be practiced twice a week.
Therefore, in children and adolescents, dynamic activ- ities will be favored, as well as balance and flexibility exercises.
PA has to be gradually settled into everyday life with progressive intensity and frequency, as well as adapted to the current level of fitness and health status. It is more important to comply with continuity and regularity principles as a priority rather than focus on the intensity of the PA.
Anyway, even if the occurrence of COVID-19 symp- toms are less frequent and milder in young people, it cannot be excluded that a febrile state requires stopping moderate to very high PA. The risk of myocarditis is in- herent in any viral infection; these inflammations of the myocardium can lead to arrhythmia, which can turn out to sudden death from exercise. For safety reasons, PA has to be stopped if fever or other suspected clinical signs of COVID-19 (fatigue, dry cough, etc.) occur. The risk of spreading the virus in the cardiac tissue such as adenovirus, parvovirus, and herpesvirus is well known, but whether this risk of complication also exists for cor- onaviruses, including SARS-CoV-2 is unknown. Abso- lute rest for fever is an intangible rule.
Moreover, even if under lockdown conditions, the in- tensities and durations of cardiorespiratory exercises are not likely to reach levels such that one can fear a fall in immune defenses in the hours that follow the activity, it is reasonable to ensure that exercises are not exhausting.
1
https://www.anses.fr/en/content/ensuring-sufficient-vitamin-d-intake-
through-diet-during-lockdown
From former to adapted benchmarks: sedentary behaviors SB in this context is a major concern, especially for young people. Sedentary lifestyle benchmarks for chil- dren until 17 years: Limit the total daily duration of sedentary activities while awake; limit the duration of each sedentary activity, so as not to exceed 1 h con- tinuously for children under 6 and 2 h for children aged 6–17 years.
In children under 6 years and in children 6 to 17 years, the sedentary lifestyle benchmarks should be adapted during the lockdown period to ensure limit sedentary time while maintaining a playful and regular PA As well as all populations, it has to be emphasized that the pace of breaking inactivity by limiting time sitting continu- ously has to rise every 30 min. Because of the well- known, and to date documented effects, parents have to ensure prevention in the increase in recreational and passive screen time that can be consecutive to lockdown being aware to strongly limit time screen to less than 60 min in young children (2–4 years) as recommended by WHO [15].
The full effectiveness of these benchmarks, as prior- itized in Table 2, also depends on compliance with general rules and habits of healthy living in confined spaces, including mental health preservation, sleep quality, and diet.
Conclusions
In the context of the actual lockdown, and considering the necessity of empowering people to preserve their own health, Anses has proposed adapted benchmarks in the continuation of the former [1] to allow, or at least fa- cilitate, the adaptation to the specific context of lock- down for all the populations.
Not much is known about the long-term mental health effects of lockdown on children and adolescents, but it can be hypothesized that some of them could adopt or reinforce unhealthy behaviors. Considering children and adolescents, the emerging risk justifies proposing specific adaptations and type of activities in order to avoid the in- stallation of unhealthy habits and ensure maintaining health underpinned, at least partly, by physiological health and physical fitness. Moreover, attention payed to PI and Table 1 Anses ’ benchmarks adapted in the context of lockdown
Duration and frequency Intensity level Exercises to adjust depending on the type of housing (with or without outdoors)
PA for children under 6 years At least 3 h of PA throughout the day:
Keep PA both frequent and playful
Activities (play, run, jump) in safe spaces indoor and outdoor (if available)
That being 15 min/h for 12 h of awake time
Make board games more active by introducing balance and stretching challenges
Use a mat for somersaults PA for children and adolescents from 6 to 17 years (including muscle strenght training activities)
At least 60 min of PA throughout the day
At least two 10 min sessions of moderate intensity
Use household items, as well as stairs and furniture to train the muscles
Record duration of PA Make board games more active by introducing balance and stretching
challenges Divide the daily duration of
physical activity in sessions of 10 to 20 min
Muscle strength training activities twice a week
Moderate intensity Exercises using the body weight or a wall (stand and sit, push, lean on), small equipment (elastic bands, weighted arm bands, dumbbells) or muscle training gear (rowing machine, training bicycle)
Use household items as exercise equipment (bottles, broom...) Limit SB of children under 6 years and children and adolescents from 6 to 17 years
Limit sedentary time. Reduce SB more frequently by breaking up prolonged sitting time
Limit the increasing leisure-based and passive screen time Ideally stand up every 30 min
Limit leisure-based and passive screen time
Table 2 Priorities for PA and SB benchmark in a lockdown situation (adapted from [2])
Children < 6 y Children and adolescents 6-17 y
SB limitation +++ +++
Muscle strength + ++
Cardiorespiratory + ++
Balance ++ +
Flexibility + +
Margaritis et al. Archives of Public Health (2020) 78:52 Page 4 of 6
SB limitation is a unique leverage to deal with already ob- served outcomes in a Chinese study: it allows to relieve children’s distress and address their concerns regarding the negative condition they are experiencing [12].
The situation of lockdown inevitably induces adoption of a sedentary lifestyle and eating habits that are not fa- vorable to health. SB such as watching TV and use of computer/games are relatively stable behaviors which track moderately in childhood and adolescence [16] and from early childhood to later in life. In the same way, PI appears as a stable behavior throughout childhood and adolescence. Reducing continuous sedentary times by frequent interruptions may help to alleviate the hypothe- sized harmful effects of even reduced PA. The probable increase in the time dedicated to leisure screens used passively can be considered as being a priority vigilance point to ensure the limitation of these durations. Indeed, PI in itself is an unhealthy habit with consequences on adulthood [17].
Children and adolescents are likely to adopt adverse behavioral and eating habits on health whose reversibil- ity is to date unknown but can at least be prevented.
Overall, it is proposed that promotional and videos could motivate children to have a healthy lifestyle at home by increasing PA, having a balanced diet, regular sleep pattern [18]. However, to be safe, this elicitation has to be considered on the basis of evidence-based benchmark involving the scientific and educational community.
In usual conditions, the link between socioeconomic status and SB which are negatively associated [19] is well known. This relationship is similar with PA [1]. During the current COVID-19 epidemic the high levels of anx- iety and stress or depression, the social capital of people on lockdown were inversely correlated too [20]. As the role of social inequalities with regard to the practice of PA and SB is already well known and the probability of perpetuating them or even worsening them in a lock- down situation is obviously high.
To our knowledge, studies on the effect of pan- demic lockdown in children and adolescents are scarce. However, despite the existence of additional factors (linked to duration, social ties, etc.), it has been considered that the behavior of children staying at home during school holidays or at weekends can be partially transposed to this assessment of the lookdown-related risk [2]. As schools can actively promote a health-conscious schedule, including PA, school closure and home confinement leads de facto to the privation of this promoting effect as an add- itional factor to the space restriction for movement.
In this context, families need help through bench- marks to ensure the continuance of both PA motiv- ation and SB limitation.
It has to be kept in mind, that, as an evidence, COVID-19 appears to be preferentially virulent among adults with existing comorbidities including obesity, hypertension, and diabetes which prevalence is known, at least partly, to be linked with lifestyle. We hypothesize this health crisis has the potential to trigger further out- comes. The very special situation we are facing could affect durably some behaviors, especially in young people. Consequently, we have to be aware as to keep sufficient pressure on the preventive effects of PA and limited SB. Since the beginning of the epidemic and the establishment of lockdown in a large number of coun- tries, a part of the scientific community reiterates that modifiable lifestyle factors like diet and PA should not be marginalized. The main concern could be the emer- gence of new unhealthy habits or routines that young people could keep after lockdown and what these ad- justed benchmarks could help to avoid. Hitherto, the lack of experience of this situation does not allow not neglect the risk.
Ensuring adequate PA for the duration of the lock- down would thus help to limit the consequences of PI and SB, and, in the present context, to maintain habits after the lockdown has ended. It will also help the re- sumption of usual activities or the acquisition of new ones and ensure a better resilience of the way out of lockdown.
Abbreviations
Anses: Agence nationale de sécurité sanitaire de l ’ alimentation, de l ’ environnement et du travail (French Agency for Food, Environmental and Occupational Health & Safety); PA: Physical activity; PI: Physical inactivity;
SB: Sedentary behaviors
Acknowledgements Not Applicable.
Authors ’ contributions
All authors participated in acquisition, analysis, or interpretation of current knowledge. IM drafted the manuscript. AV, PD and SH revised of the manuscript for intellectual content. All authors read and approved the final manuscript.
Funding
This work was supported by French Agency for Food, Environmental and Occupational Health & Safety (Anses).
Availability of data and materials Not applicable.
Ethics approval and consent to participate Not applicable.
Consent for publication Not applicable.
Competing interests
The authors declare that they have no competing interests.
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